Shock

CMSgt John Jonckers, RN, NREMT-P
Superintendent 141st MDG
SMEE - Thailand

1. 1
Hemorrhage
& Shock
CMSgt John Jonckers, RN, NREMT-P
Superintendent 141
st
MDG
SMEE - Thailand

2. 2
Review of Hemorrhage
nLocation
nAnatomical Type & Timing
nCoagulation
nFibrinolysis
nAssessment
nManagement

3. 3
Review of Hemorrhage
nLocation
–External
–Internal
•Traumatic
•Non-Traumatic
nExamples?

4. 4
Review of Hemorrhage
nAnatomical Type
–Arterial
–Venous
–Capillary
nTiming
–Acute
–Chronic

5. 5
Management of Hemorrhage
nAirway and Ventilatory Support
nCirculatory Support
–From nose or ears after head trauma = loose drsg
–Control bleeding
•direct pressure, elevation, pressure points
•tourniquet
•packing of large wounds
•splinting
•PASG
•transport to appropriate facility

6. 6
Shock
Inadequate peripheral
perfusion leading to failure of
tissue oxygenation
 may lead to anaerobic metabolism

7. 7
Shock
nHomeostasis
–cellular state of balance
–perfusion of cells with oxygen and
glucose is one of its cornerstones
–Transfer of waste materials from the
cell to blood for elimination

8. 8
Fick Principle
Air’s gotta go in and out.
Blood’s gotta go round and round.
Any variation of the above is not a
good thing!

9. 9
Shock
Inadequate oxygenation or
perfusion causes:
uInadequate cellular oxygenation
uShift from aerobic to anaerobic
metabolism

10. 10
AEROBIC METABOLISM
6 O
2
GLUCOSE
METABOLISM
6 CO
2
6 H
2
O
36 ATP
HEAT (417 kcal)
Glycolysis: Inefficient source of energy production; 2
ATP for every glucose; produces pyruvic acid
Oxidative phosphorylation: Each pyruvic acid is
converted into 34 ATP

11. 11
ANAEROBIC METABOLISM
GLUCOSE METABOLISM
2 LACTIC ACID
2 ATP
HEAT (32 kcal)
Glycolysis: Inefficient source of energy production; 2
ATP for every glucose; produces pyruvic acid

12. 12
Anaerobic Metabolism
nOccurs without oxygen
–oxydative phosphorylation can’t occur
without oxygen
–glycolysis can occur without oxygen
–cellular death leads to tissue and organ
death
–can occur even after return of perfusion
 organ or organism death

13. 13
Maintaining perfusion
requires:
nVolume = blood
nPump = heart
nContainer = Vessels
nFailure of one or more of these
causes shock

14. 14
Shock Classifications
nHypovolemic
nCardiogenic
nVasogenic (Distributive)
nNeurogenic

15. 15
Shock
nHypovolemic Shock = Low Volume
nA leak in the vessel
–Trauma
–Non-traumatic
blood loss
Vaginal
GI
GU
–Burns
–Diarrhea
–Vomiting
–Diuresis
–Sweating
–Third space losses
Pancreatitis
Peritonitis
Bowel obstruction

16. 16
Shock
nCardiogenic Shock = Pump
Failure
nPump not working efficiently
–Acute M I
–CHF
–Bradyarrhythmias
–Tachyarrhythmias
–Mechanical
obstruction
(“distributive shock”)
Cardiac tamponade
Tension pneumothorax
Pulmonary embolism

17. 17
Shock
nVasogenic Shock = Low Resistance
nContainer got larger or holds more
–Spinal cord trauma
•neurogenic shock
–Depressant drug toxicity
–Simple fainting

18. 18
Shock
nMixed Shock
–Septic Shock
•Overwhelming infection
•Inflammatory response occurs
•Blood vessels
–Dilate (loss of resistance)
–Leak (loss of volume)

19. 19
Shock
nMixed Shock
–Septic Shock
•Fever
–Increased O
2
demand
–Increased anaerobic metabolism
•Bacterial toxins
–Impaired tissue metabolism

20. 20
Shock
nMixed Shock
–Anaphylactic Shock
•Severe allergic reaction
•Histamine is released
•Blood vessels
–Dilate (loss of resistance)
–Leak (loss of volume)

21. 21
Shock
nMixed Shock
–Anaphylactic Shock
•Histamine release
•Extravascular smooth muscle spasm
–Laryngospasm
–Bronchospasm

22. 22
Compensated Shock
nPresentation
–Restlessness, anxiety
•Earliest sign of shock
–Tachycardia
•?Bradycardia in cardiogenic,
neurogenic

23. 23
Compensated Shock
nPresentation
–Normal BP, narrow pulse pressure
–Falling BP = late sign of shock
–Mild orthostatic hypotension (15 to
25 mm Hg)
–“Possible” delay in capillary refill

24. 24
Compensated Shock
nPresentation
–Pale, cool skin
•Cardiogenic
•Hypovolemic
–Flushed skin
•Anaphylactic
•Septic
•Neurogenic

25. 25
Compensated Shock
nPresentation continued
–Slight tachypnea
–Respiratory compensation for
metabolic acidosis

26. 26
Compensated Shock
nPresentation
–Nausea, vomiting
–Thirst
–Decreased body temperature
–Feels cold
–Weakness

27. 27
Decompensated Shock
nPresentation
–Peripheral effects
•Relaxation of precapillary
sphincters
•Continued contraction of
postcapillary sphincters
•Peripheral pooling of blood
•Plasma leakage into interstitial
spaces

28. 28
Decompensated Shock
nPresentation
–Peripheral effects
•Continued anaerobic
metabolism
•Continued increase in
extracellular potassium
•Cold, gray, “waxy” skin

29. 29
Decompensated Shock
nPresentation
–Listlessness, confusion, apathy, slow
speech
–Tachycardia; weak, thready pulse
–Decreased blood pressure
–Moderate to severe orthostatic
hypotension
–Decreased body temperature
–Tachypnea

30. 30
Irreversible Shock
nPresentation
–Confusion, slurred speech, unconscious
–Slow, irregular, thready pulse
–Falling BP; diastolic goes to zero
–Cold, clammy, cyanotic skin
–Slow, shallow, irregular respirations
–Dilated, sluggish pupils
–Severely decreased body temperature

31. 31
Irreversible Shock
nIrreversible shock leads to:
–Renal failure
–Hepatic failure
–Disseminated intravascular
coagulation (DIC)
–Multiple organ systems failure
–Adult respiratory distress syndrome
(ARDS)
–Death

32. 32
Shock Classifications
nHypovolemic Causes
–Hemorrhage
–Plasma
–Fluid & Electrolytes
–Endocrine

33. 33
Shock Classifications
nCardiogenic Causes
–Contractility
–Rate
–Obstructive (Preload/Afterload)
•Tension pneumothorax
•Pericardial tamponade
•Pulmonary embolism
•Severe Hypertension

34. 34
Shock Classifications
nVasogenic (distributive)
–Increased venous capacitance
–low resistance, vasodilation
•anaphylaxis
•sepsis

35. 35
Shock Classifications
nNeurogenic (spinal shock)
–loss of spinal cord function below
site of injury
–loss of sympathetic tone
•cutaneous vasodilation
•relative bradycardia

36. 36
Key Issues In Shock
nTissue ischemic sensitivity
–Heart, brain, lung: 4 to 6 minutes
–GI tract, liver, kidney: 45 to 60 minutes
–Muscle, skin: 2 to 3 hours
Resuscitate Critical
Tissues First!

37. 37
Key Issues In Shock
nRecognize & Treat during
compensatory phase
Best indicator of
resuscitation effectiveness =
Level of Consciousness
Restlessness, anxiety,
combativeness = Earliest
signs of shock

38. 38
Key Issues In Shock
nFalling BP = LATE sign of shock
nBP is NOT same thing as
perfusion
nPallor, tachycardia, slow capillary
refill = Shock, until proven
otherwise

39. 39
Key Issues In Shock
Isolated head trauma
does NOT cause shock
(“possible” in peds)

40. 40
General Shock Management
nAirway
–Open, Clear, Maintained
–Consider Intubation

41. 41
General Shock Management
nHigh concentration oxygen
–Oxygen = Most Important Drug in Shock
nAssist ventilation as needed
–When in Doubt, Ventilate
•BVM
nDecompress Tension Pneumothorax

42. 42
General Shock Management
nEstablish venous access
–Replace fluid
–Give drugs, as appropriate
–Don’t delay definitive therapy
n Maintain body temperature
–Cover patient with blanket if needed
–Avoid cold IV fluids

43. 43
General Shock Management
nMonitor
–Mental Status
–Pulse
–Respirations
–Blood Pressure
–ECG

44. 44
Hypovolemic Shock
nControl severe external bleeding
nElevate lower extremities
nAvoid Trendelenburg
nPneumatic anti-shock garment – if
your protocols dictate

45. 45
Hypovolemic Shock
nTwo large bore IV lines
–Infuse Lactated Ringer’s solution
–Titrate BP to 90-100 mm Hg

46. 46
Hypovolemic Shock
nDo NOT delay transport – scoop &
run.
nStart IVs enroute to hospital
Where does stabilization
of critical trauma occur?

47. 47
Cardiogenic Shock
nSupine, or head and shoulders
slightly elevated
nDo NOT elevate lower extremities

48. 48
Cardiogenic Shock
nKeep open line, TKO
nFluid challenge based on
cardiovascular mechanism and
history
–Titrate to BP ~ 90 mm Hg

49. 49
Cardiogenic Shock
nObstructive Shock
–Treat the underlying cause
•Tension Pneumothorax
•Pericardial Tamponade
–Isotonic fluids titrated to BP w/o
pulmonary edema
–Control airway
•Intubation

50. 50
Shock Management
Avoid vasopressors
until hypovolemia ruled
out, or corrected

51. 51
Vasogenic Shock
nConsider need to assist ventilations
nPatient supine; lower extremities
elevated
nAvoid Trendelenburg

52. 52
Vasogenic Shock
nInfuse isotonic crystalloid
–“Top off tank”
nConsider possible hypovolemia
nConsider vasopressors

53. 53
Vasogenic Shock
nMaintain body temperature
nHypothermia may occur

54. 54
Vasogenic Shock
nAnaphylaxis
–Suppress inflammatory response
•Antihistamines
•Corticosteroids
–Oppose histamine response
•Epinephrine
–bronchospasm & vasodilation
–Replace intravascular fluid
•Isotonic fluid titrated to BP ~ 90 mm

55. 55
Shock in Children
nSmall blood volume
–Increased hypovolemia risk
nVery efficient compensatory
mechanisms
–Failure may cause “sudden”
shock
nPallor, altered LOC, cool skin =
shock UPO

56. 56
Shock in Children
nAvoid massive fluid infusion
–Use 20 cc/kg boluses
nHigh surface to volume ratio
–Increased hypothermia risk